Provider Demographics
NPI:1619001765
Name:MADDOX, REID (LMT)
Entity Type:Individual
Prefix:
First Name:REID
Middle Name:
Last Name:MADDOX
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 GARY ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4638
Mailing Address - Country:US
Mailing Address - Phone:479-739-5555
Mailing Address - Fax:
Practice Address - Street 1:2301 S 56TH ST
Practice Address - Street 2:SIUTE 104
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3755
Practice Address - Country:US
Practice Address - Phone:479-739-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2163225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist